“Well, do you want an alive son or a dead daughter?”
It is the question that should never be asked. It is the question that vetoes all others.
For the worried, loving mother, desperate to help her precious child, it elicits tears and resignation to a new reality. For the angry, defensive father, desperate to keep his precious child safe, it disarms him, the chamber is now empty. The battle is lost.
From the health professionals in Australia’s Gender Clinics, this narrative is often presented as a choice: “affirm or suicide” or “transition or death”. Clearly, this is not a choice, but an ultimatum.
But is it true? That is the fundamental question I want to answer for Australian parents. I am an experienced Australian medical specialist who can read scientific literature, analyse and apply it to the real world. My bias is I too am a father and my children are precious.
The question above is an absolute, it means life or death. It is not whether the child contemplates suicide, discusses suicide, plans suicide, or even attempts suicide. The premise put to parents is without gender affirming care their child will die, a suicide will happen. That is the confronting question to answer.
I think we can concede the obvious. Children experiencing “gender dysphoria” have a high incidence of suicidal thoughts. There is plenty of evidence to support this. Whatever has led them to the gender clinic, they are in distress and disturbed. Anxiety, fear, depression, sadness, self-loathing, shame, embarrassment, anger, isolation, loneliness, and resentment are just some potential emotions experienced. To hear they may, at times, contemplate ending their suffering by suicide is not surprising, despite being horrifying.
So now let us discuss two real choices for this child….
1. We go on a classical “watchful waiting” path; where the child is reassured but not affirmed; given counselling, surveillance and help as they progress through natural puberty into adolescence and adulthood. They grow normal, healthy secondary sexual characteristics, normally functioning sex organs and a mature body shape, one genetically pre-programmed to be. The natural sex hormones released modify their brain over years, thus changing their thoughts and feelings about themselves and their sex. They vast majority desist in their dysphoria and come to accept their sex and their body1,2,3. Many are same sex attracted3. Those who don’t desist become gender dysphoric adults with a matured brain, body and life experience, who can self-consent on how to proceed next.
2. We embrace a “gender affirming care” model. One where the patient is believed at all times, affirmed as correct in their dysphoria and assisted with their wishes. Puberty blockers are commenced to prevent their natural pubertal growth and development. In over 95% of cases, this will lead to the commencement of cross-sex hormones, stimulating the development of secondary sexual characteristics of the opposite sex. A new name is chosen, new clothes, new hairstyle. Girls may wear chest binders and shave to stimulate facial hair growth, boys may start “tucking”. The school is informed and all join in affirming the new identity. Once they have reached the age of consent, surgeries can commence to remove rejected sex organs and create poorly functioning (or non-functioning) replicas of the opposite sex. Side effects of the chemicals are universal, complication rates of surgeries are high and fatalities have been reported. What is produced is a person of ambiguity, requiring chemical maintenance for the duration of their life.
Gender Affirming Care health professionals believe their model, option 2, is “The Gold Standard” and will protect your child from suicide. In their opinion, “Watchful waiting” (option 1) is the death trap.
It is at this point that my “Common-Sense Radar” pricks up, I imagine yours does too. Common sense isn’t measured in scientific studies, and therefore often ignored in medicine. I can’t help but reject their premise before even considering the evidence, it is too ludicrous to contemplate.
But I must. I must see if there truly is scientific evidence that gender dysphoric children put into a “gender affirming care” pathway have lower rates of suicide than those on a “watchful waiting” pathway. The state of Victoria considers “watchful waiting” conversion therapy and made it illegal, despite being the standard model used in many countries around the world.
The Evidence
Is there a systematic review of multiple, large, double blind, randomised, control trials of gender dysphoric children (or adults) put into either pathway, followed for many years, assessing the incidence of suicide and other outcomes? That would constitute the best available scientific evidence known to the medical profession.
No there is not.
Is there a SINGLE double blind, randomised, control trial on this question? That would be the next highest level of evidence.
No there is not.
Is there ANY type of trial that directly compares these two pathways against each other for groups of gender dysphoric children (or adults) over time and measures suicide outcomes?
No there is not.
So before I read a single shred of evidence, I can say the QUALITY of evidence in this field is low. We will be delving into the areas of observational data, cohorts, case reports, and the dreaded survey, which is by far the lowest level of scientific evidence available.
What is left? To be honest not much. A review article in March 2023, which was published in a non-peer reviewed, open access platform, looked at this question4. The author, Daniel Jackson, titled the paper: “Suicide-Related Outcomes Following Gender- Affirming Treatment: A Review”.
In his thorough search, Jackson found 23 scientific papers in the medical literature that were relevant. The breakdown of these papers was disappointing. 8 were cohorts (small groups) of patients who received gender affirming treatments only, so there was no “watchful waiting” comparison group. 14 were surveys of patients, which are useless when trying to find out if a patient is dead, as they don’t generally fill out surveys. The last study was a whole population database search which gives only crude information.
What does Jackson’s review tell us? The most important finding is that “gender affirming care” or gender affirming treatments were not protective for suicide. Multiple papers reviewed showed among patients who received “gender affirming care” or gender affirming treatments, completed suicides still occurred, 10% of patients in one Danish study. The “alive son” may not be alive after all.
This finding is confirmed in other studies.
The Netherlands has a long history of embracing transgender medicine. Dutch researchers were the first to study the administration of puberty blockers and cross-sex hormones to children, followed by genital surgeries and published in 2006 what they claim were groundbreaking positive results. From this came “The Dutch Protocol”; the original set of guidelines that formed the basis of all gender affirming care models today.
However, a recently published long term follow-up study of these transgender patients tells a different story5. Most importantly to us, treated patients were still at higher risk of suicide. Overall, 8 in every 1000 transwomen and 3 in every 1000 transmen suicided. This was 4 times higher than the suicide rate in the general Dutch population at the time studied (2013-2017). See an exert from the paper below:
In a very large and long retrospective follow-up study in the Netherlands, 8263 transgender patients, those who had transitioned, were followed for up to 45 years to look for suicide risk. They found a trans-women suicide rate of 0.8% (per 100,000 person years) and 0.3% (29 per 100,000 person years) in trans-men.5
In Sweden, a country that was an early adopter of a “gender affirmation model”, the story is the same6. In a long term follow-up study, the odds of suicide in people who underwent sex reassignment surgeries was 19 times more than their matched controls in the general population. See an exert from the paper below:
Mortality from suicide was strikingly high among sex-reassigned persons, also after adjustment for prior psychiatric morbidity. In line with this, sex-reassigned persons were at increased risk for suicide attempts. Previous reports [6,8,10,11] suggest that transsexualism is a strong risk factor for suicide, also after sex reassignment, and our long-term findings support the need for continued psychiatric follow-up for persons at risk to prevent this.6
Finally, and very importantly, in a study in America, a cohort of 315 adolescents aged 12-20 years were followed in “gender affirming care” clinics for a period of 2 years after the initiation of cross sex hormones7. Alarmingly, 2 youths suicided during the study, and 11 others had suicidal ideation.
I think it’s fair to say at this point, the “alive son” part of our question is hyperbole at best and outright fallacy at worst. That alone should enrage every parent.
But I need to look at the other half of the question. What effect does the “watchful waiting” model have on suicide?
The biggest data set comes from the infamous Tavistock Clinic in London8. They looked at all patients from 2010-2020 who were either being treated at the Gender Identity Development Service or on the waitlist. Of the 15,032 children seen at the clinic or on the waitlist, 4 had committed suicide over the 11 year study period. That’s a suicide rate 5.5 times higher than the general adolescent population, a rate of 13 suicides per 100,000 children with gender dysphoria.
But most importantly, 2 suicides were in children on the waitlist, and therefore not receiving any form of treatment, while 2 suicides were children in treatment at the clinic under a “gender affirming care” model. As there was a relatively even split of patients being treated and on the waitlist in the study, it is clear there was no difference in suicide rates in the patient groups.
The author concluded:
The fact that deaths were so rare should provide some reassurance to transgender youth and their families, though of course this does not detract from the distress caused by self-harming behaviours that are non-fatal. It is irresponsible to exaggerate the prevalence of suicide8.
So in conclusion, what is the truth to the question: “Well do you want an alive son or a dead daughter?”
The truth is this: it is a lie.
All children with gender dysphoria have an increased risk of suicide compared to the general population. Your child, with or without puberty blockers, cross-sex hormones and surgeries has a very low chance of killing themselves, but it is higher than children without gender dysphoria. “Gender affirming care” does nothing to change this risk.
“Well, do you want an alive son or a dead daughter?” should never be said to parents by any “gender affirming care” health professional. Not only is it emotional blackmail, but also a reductionist lie. It serves to coerce in a most unethical way, by threatening parents as accomplices to the death of their child. It is beyond misinterpretation, exaggeration, good intentions, or an honest mistake. It is evil, pure and simple.
Anon.
September 2023
1. Jiska Ristori & Thomas D. Steensma (2016) Gender dysphoria in childhood. International Review of Psychiatry, 28:1, 13-20, DOI: 10.3109/09540261.2015.1115754
2. Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clin Child Psychol Psychiatry. 2011 Oct;16(4):499-516. doi: 10.1177/1359104510378303. Epub 2011 Jan 7. PMID: 21216800.
3. Singh D, Bradley SJ, Zucker KJ. A Follow-Up Study of Boys With Gender Identity Disorder. Front Psychiatry. 2021 Mar 29;12:632784. doi: 10.3389/fpsyt.2021.632784. PMID: 33854450; PMCID: PMC8039393.
4. Jackson D (March 20, 2023) Suicide-Related Outcomes Following Gender-Affirming Treatment: A Review. Cureus 15(3): e36425. DOI 10.7759/cureus.36425
5. Wiepjes, CM, den Heijer, M, Bremmer, MA, Nota, NM, de Blok, CJM, Coumou, BJG, Steensma, TD. Trends in suicide death risk in transgender people: results from the Amsterdam Cohort of Gender Dysphoria study (1972–2017).
6. Dhejne C, Lichtenstein P, Boman M, Johansson AL, Långström N, Landén M: Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS One. 2011, 6:e16885. 10.1371/journal.pone.0016885
7. Chen D, Berona J, Chan YM et al. Psychosocial Functioning in Transgender Youth after 2 years of Hormones. New Eng J Med 2023; 388:240-250. DOI: 10.1056/NEJMoa2206297
8. Biggs M. Suicide by Clinic-Referred Transgender Adolescents in the United Kingdom. Arch Sex Behav 51, 685–690 (2022). https://doi.org/10.1007/s10508-022-02287-7
It is evil & it was done to us. When we refuted the affirm or your child will die narrative we were shamed in front of our daughter, called abusive & unsupportive parents. From that point our relationship with our daughter deteriorated as we became the “unsupportive enemy “. Five years on we are estranged. We have lost faith in humanity. So many people are mindlessly cheering on such egregious harm. I know so many parents whose hearts have been broken.
Agree with the strength of your concluding paragraph.
The question is also a classic logical fallacy - that of the false dichotomy.
Thanks for your much needed and excellent writing.